1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the [2005] recommendations. The guideline addendum gives details of the methods and the evidence used to develop the [2015] and [new 2015] recommendations.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

1.1 Care of all children and young people with depression

1.1.1 Good information, informed consent and support

1.1.1.1 Children and young people and their families need good information, given as part of a collaborative and supportive relationship with healthcare professionals, and need to be able to give fully informed consent. [2005]

1.1.1.2 Healthcare professionals involved in the detection, assessment or treatment of children or young people with depression should ensure that information is provided to the patient and their parent(s) and carer(s) at an appropriate time. The information should be age appropriate and should cover the nature, course and treatment of depression, including the likely side‑effect profile of medication should this be offered. [2005]

1.1.1.3 Healthcare professionals involved in the treatment of children or young people with depression should take time to build a supportive and collaborative relationship with both the patient and the family or carers. [2005]

1.1.1.4 Healthcare professionals should make all efforts necessary to engage the child or young person and their parent(s) or carer(s) in treatment decisions, taking full account of patient and parental/carer expectations, so that the patient and their parent(s) or carer(s) can give meaningful and properly informed consent before treatment is initiated. [2005]

1.1.1.5 Families and carers should be informed of self‑help groups and support groups and be encouraged to participate in such programmes where appropriate. [2005]

1.1.2 Language and ethnic minorities

1.1.2.1 Where possible, all services should provide written information or audiotaped material in the language of the child or young person and their family or carer(s), and professional interpreters should be sought for those whose preferred language is not English. [2005]

1.1.2.2 Consideration should be given to providing psychological therapies and information about medication and local services in the language of the child or young person and their family or carers where the patient's and/or their family's or carer's first language is not English. If this is not possible, an interpreter should be sought. [2005]

1.1.2.3 Healthcare professionals in primary, secondary and relevant community settings should be trained in cultural competence to aid in the diagnosis and treatment of depression in children and young people from black and minority ethnic groups. This training should take into consideration the impact of the patient's and healthcare professional's racial identity status on the patient's depression. [2005]

1.1.2.4 Healthcare professionals working with interpreters should be provided with joint training opportunities with those interpreters, to ensure that both healthcare professionals and interpreters understand the specific requirements of interpretation in a mental health setting. [2005]

1.1.2.5 The development and evaluation of services for children and young people with depression should be undertaken in collaboration with stakeholders involving patients and their families and carers, including members of black and minority ethnic groups. [2005]

1.1.3 Assessment and coordination of care

1.1.3.1 When assessing a child or young person with depression, healthcare professionals should routinely consider, and record in the patient's notes, potential comorbidities, and the social, educational and family context for the patient and family members, including the quality of interpersonal relationships, both between the patient and other family members and with their friends and peers. [2005]

1.1.3.2 In the assessment of a child or young person with depression, healthcare professionals should always ask the patient and their parent(s) or carer(s) directly about the child or young person's alcohol and drug use, any experience of being bullied or abused, self‑harm and ideas about suicide. A young person should be offered the opportunity to discuss these issues initially in private. [2005]

1.1.3.3 If a child or young person with depression presents acutely having self‑harmed, the immediate management should follow the NICE guideline Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care as this applies to children and young people, paying particular attention to the guidance on consent and capacity. Further management should then follow this depression guideline. [2005]

1.1.3.4 In the assessment of a child or young person with depression, healthcare professionals should always ask the patient, and be prepared to give advice, about self‑help materials or other methods used or considered potentially helpful by the patient or their parent(s) or carer(s). This may include educational leaflets, helplines, self‑diagnosis tools, peer, social and family support groups, complementary therapies, and religious and spiritual groups. [2005]

1.1.3.5 Healthcare professionals should only recommend self‑help materials or strategies as part of a supported and planned package of care. [2005]

1.1.3.6 For any child or young person with suspected mood disorder, a family history should be obtained to check for unipolar or bipolar depression in parents and grandparents. [2005]

1.1.3.7 When a child or young person has been diagnosed with depression, consideration should be given to the possibility of parental depression, parental substance misuse, or other mental health problems and associated problems of living, as these are often associated with depression in a child or young person and, if untreated, may have a negative impact on the success of treatment offered to the child or young person. [2005]

1.1.3.8 When the clinical progress of children and young people with depression is being monitored in secondary care, the self‑report Mood and Feelings Questionnaire (MFQ) should be considered as an adjunct to clinical judgement. [2005]

1.1.3.9 In the assessment and treatment of depression in children and young people, special attention should be paid to the issues of:

  • confidentiality

  • the young person's consent (including Gillick competence)

  • parental consent

  • child protection

  • the use of the Mental Health Act in young people

  • the use of the Children Act. [2005]

1.1.3.10 The form of assessment should take account of cultural and ethnic variations in communication, family values and the place of the child or young person within the family. [2005]

1.1.4 The organisation and planning of services

1.1.4.1 Healthcare professionals specialising in depression in children and young people should work with local CAMHS to enhance specialist knowledge and skills regarding depression in these existing services. This work should include providing training and help with guideline implementation. [2005]

1.1.4.2 CAMHS and local healthcare commissioning organisations should consider introducing a primary mental health worker (or CAMHS link worker) into each secondary school and secondary pupil referral unit as part of tier 2 provision within the locality. [2005]

1.1.4.3 Primary mental health workers (or CAMHS link workers) should establish clear lines of communication between CAMHS and tier 1 or 2, with named contact people in each tier or service, and develop systems for the collaborative planning of services for young people with depression in tiers 1 and 2. [2005]

1.1.4.4 CAMHS and local healthcare commissioning organisations should routinely monitor the rates of detection, referral and treatment of children and young people, from all ethnic groups, with mental health problems, including those with depression, in local schools and primary care. This information should be used for planning services and made available for local, regional and national comparison. [2005]

1.1.4.5 All healthcare and CAHMS professionals should routinely use, and record in the notes, appropriate outcome measures (such as those self‑report measures used in screening for depression or generic outcome measures used by particular services, for example Health of the Nation Outcome Scale for Children and Adolescents [HoNOSCA] or Strengths and Difficulties Questionnaire [SDQ]), for the assessment and treatment of depression in children and young people. This information should be used for planning services, and made available for local, regional and national comparison. [2005]

1.1.5 Treatment considerations in all settings

1.1.5.1 Most children and young people with depression should be treated on an outpatient or community basis. [2005]

1.1.5.2 Before any treatment is started, healthcare professionals should assess, together with the young person, the social network around him or her. This should include a written formulation, identifying factors that may have contributed to the development and maintenance of depression, and that may impact both positively or negatively on the efficacy of the treatments offered. The formulation should also indicate ways that the healthcare professionals may work in partnership with the social and professional network of the young person. [2005]

1.1.5.3 When bullying is considered to be a factor in a child or young person's depression, CAMHS, primary care and educational professionals should work collaboratively to prevent bullying and to develop effective antibullying strategies. [2005]

1.1.5.4 Psychological therapies used in the treatment of children and young people with depression should be provided by therapists who are also trained in child and adolescent mental health. [2005]

1.1.5.5 Psychological therapies used in the treatment of children and young people with depression should be provided by healthcare professionals who have been trained to an appropriate level of competence in the specific modality of psychological therapy being offered. [2005]

1.1.5.6 Therapists should develop a treatment alliance with the family. If this proves difficult, consideration should be given to providing the family with an alternative therapist. [2005]

1.1.5.7 Comorbid diagnoses and developmental, social and educational problems should be assessed and managed, either in sequence or in parallel, with the treatment for depression. Where appropriate this should be done through consultation and alliance with a wider network of education and social care. [2005]

1.1.5.8 Attention should be paid to the possible need for parents' own psychiatric problems (particularly depression) to be treated in parallel, if the child or young person's mental health is to improve. If such a need is identified, then a plan for obtaining such treatment should be made, bearing in mind the availability of adult mental health provision and other services. [2005]

1.1.5.9 A child or young person with depression should be offered advice on the benefits of regular exercise and encouraged to consider following a structured and supervised exercise programme of typically up to three sessions per week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks. [2005]

1.1.5.10 A child or young person with depression should be offered advice about sleep hygiene and anxiety management. [2005]

1.1.5.11 A child or young person with depression should be offered advice about nutrition and the benefits of a balanced diet. [2005]

1.2 Stepped care

The stepped‑care model of depression draws attention to the different needs that depressed children and young people have – depending on the characteristics of their depression and their personal and social circumstances – and the responses that are required from services. It provides a framework in which to organise the provision of services that support both healthcare professionals and patients and their parent(s) or carer(s) in identifying and accessing the most effective interventions (see Table 1).

Table 1 The stepped-care model

Focus

Action

Responsibility

Detection

Risk profiling

Tier 1

Recognition

Identification in presenting children or young people

Tiers 2–4

Mild depression (including dysthymia)

Watchful waiting

Non‑directive supportive therapy/group cognitive behavioural therapy/guided self‑help

Tier 1

Tier 1 or 2

Moderate to severe depression

Brief psychological therapy
+/– fluoxetine

Tier 2 or 3

Depression unresponsive to treatment/recurrent depression/psychotic depression

Intensive psychological therapy
+/– fluoxetine, sertraline, citalopram, augmentation with an antipsychotic

Tier 3 or 4

The guidance follows these five steps.

1. Detection and recognition of depression and risk profiling in primary care and community settings.

2. Recognition of depression in children and young people referred to CAMHS.

3. Managing recognised depression in primary care and community settings – mild depression.

4. Managing recognised depression in tier 2 or 3 CAMHS – moderate to severe depression.

5. Managing recognised depression in tier 3 or 4 CAMHS – unresponsive, recurrent and psychotic depression, including depression needing inpatient care.

Each step introduces additional interventions; the higher steps assume interventions in the previous step. [2005]

1.3 Step 1: Detection, risk profiling and referral

1.3.1 Detection and risk profiling

1.3.1.1 Healthcare professionals in primary care, schools and other relevant community settings should be trained to detect symptoms of depression, and to assess children and young people who may be at risk of depression. Training should include the evaluation of recent and past psychosocial risk factors, such as age, gender, family discord, bullying, physical, sexual or emotional abuse, comorbid disorders, including drug and alcohol use, and a history of parental depression; the natural history of single loss events; the importance of multiple risk factors; ethnic and cultural factors; and factors known to be associated with a high risk of depression and other health problems, such as homelessness, refugee status and living in institutional settings. [2005]

1.3.1.2 Healthcare professionals in primary care, schools and other relevant community settings should be trained in communications skills such as 'active listening' and 'conversational technique', so that they can deal confidently with the acute sadness and distress ('situational dysphoria') that may be encountered in children and young people following recent undesirable events. [2005]

1.3.1.3 Healthcare professionals in primary care settings should be familiar with screening for mood disorders. They should have regular access to specialist supervision and consultation. [2005]

1.3.1.4 Healthcare professionals in primary care, schools and other relevant community settings who are providing support for a child or young person with situational dysphoria should consider ongoing social and environmental factors if the dysphoria becomes more persistent. [2005]

1.3.1.5 Child and Adolescent Mental Health Services (CAMHS) tier 2 or 3 should work with health and social care professionals in primary care, schools and other relevant community settings to provide training and develop ethnically and culturally sensitive systems for detecting, assessing, supporting and referring children and young people who are either depressed or at significant risk of becoming depressed. [2005]

1.3.1.6 In the provision of training by CAMHS professionals for healthcare professionals in primary care, schools and relevant community settings, priority should be given to the training of pastoral support staff in schools (particularly secondary schools), community paediatricians and GPs. [2005]

1.3.1.7 When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, healthcare professionals in primary care, schools and other relevant community settings should undertake an assessment of the risks of depression associated with the event and make contact with their parent(s) or carer(s) to help integrate parental/carer and professional responses. The risk profile should be recorded in the child or young person's records. [2005]

1.3.1.8 When a child or young person is exposed to a single recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, in the absence of other risk factors for depression, healthcare professionals in primary care, schools and other relevant community settings should offer support and the opportunity to talk over the event with the child or young person. [2005]

1.3.1.9 Following an undesirable event, a child or young person should not normally be referred for further assessment or treatment, as single events are unlikely to lead to a depressive illness. [2005]

1.3.1.10 A child or young person who has been exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience and is identified to be at high risk of depression (the presence of two or more other risk factors for depression), should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1 and assessed for depression. Early referral should be considered if there is evidence of depression and/or self‑harm. [2005]

1.3.1.11 When a child or young person is exposed to a recent undesirable life event, such as bereavement, parental divorce or separation or a severely disappointing experience, and where one or more family members (parents or children) have multiple‑risk histories for depression, they should be offered the opportunity to talk over their recent negative experiences with a professional in tier 1 and assessed for depression. Early referral should be considered if there is evidence of depression and/or self‑harm. [2005]

1.3.1.12 If children and young people who have previously recovered from moderate or severe depression begin to show signs of a recurrence of depression, healthcare professionals in primary care, schools or other relevant community settings should refer them to CAMHS tier 2 or 3 for rapid assessment. [2005]

1.3.2 Referral criteria

1.3.2.1 For children and young people, the following factors should be used by healthcare professionals as indications that management can remain at tier 1:

  • exposure to a single undesirable event in the absence of other risk factors for depression

  • exposure to a recent undesirable life event in the presence of two or more other risk factors with no evidence of depression and/or self‑harm

  • exposure to a recent undesirable life event, where one or more family members (parents or children) have multiple‑risk histories for depression, providing that there is no evidence of depression and/or self‑harm in the child or young person

  • mild depression without comorbidity. [2005]

1.3.2.2 For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 2 or 3 CAMHS:

  • depression with two or more other risk factors for depression

  • depression where one or more family members (parents or children) have multiple‑risk histories for depression

  • mild depression in those who have not responded to interventions in tier 1 after 2–3 months

  • moderate or severe depression (including psychotic depression)

  • signs of a recurrence of depression in those who have recovered from previous moderate or severe depression

  • unexplained self‑neglect of at least 1 month's duration that could be harmful to their physical health

  • active suicidal ideas or plans

  • referral requested by a young person or their parent(s) or carer(s). [2005]

1.3.2.3 For children and young people, the following factors should be used by healthcare professionals as criteria for referral to tier 4 services:

  • high recurrent risk of acts of self‑harm or suicide

  • significant ongoing self‑neglect (such as poor personal hygiene or significant reduction in eating that could be harmful to their physical health)

  • requirement for intensity of assessment/treatment and/or level of supervision that is not available in tier 2 or 3. [2005]

1.4 Step 2: Recognition

1.4.1.1 Children and young people of 11 years or older referred to CAMHS without a diagnosis of depression should be routinely screened with a self‑report questionnaire for depression as part of a general assessment procedure. [2005]

1.4.1.2 Training opportunities should be made available to improve the accuracy of CAMHS professionals in diagnosing depressive conditions. The existing interviewer‑based instruments (such as Kiddie‑Sads [K‑SADS] and Child and Adolescent Psychiatric Assessment [CAPA]) could be used for this purpose but will require modification for regular use in busy routine CAMHS settings. [2005]

1.4.1.3 Within tier 3 CAMHS, professionals who specialise in the treatment of depression should have been trained in interviewer‑based assessment instruments (such as K‑SADS and CAPA) and have skills in non‑verbal assessments of mood in younger children. [2005]

1.5 Step 3: Mild depression

1.5.1 Watchful waiting

1.5.1.1 For children and young people with diagnosed mild depression who do not want an intervention or who, in the opinion of the healthcare professional, may recover with no intervention, a further assessment should be arranged, normally within 2 weeks ('watchful waiting'). [2005]

1.5.1.2 Healthcare professionals should make contact with children and young people with depression who do not attend follow‑up appointments. [2005]

1.5.2 Interventions for mild depression

1.5.2.1 Discuss the choice of psychological therapies with children and young people and their family members or carers (as appropriate). Explain that there is no good‑quality evidence that one type of psychological therapy is better than the others. [new 2015]

1.5.2.2 Following a period of up to 4 weeks of watchful waiting, offer all children and young people with continuing mild depression and without significant comorbid problems or signs of suicidal ideation individual non‑directive supportive therapy, group cognitive behavioural therapy (CBT) or guided self‑help for a limited period (approximately 2 to 3 months). This could be provided by appropriately trained professionals in primary care, schools, social services and the voluntary sector or in tier 2 Child and Adolescent Mental Health Services (CAMHS). [2015]

1.5.2.3 Children and young people with mild depression who do not respond after 2 to 3 months to non‑directive supportive therapy, group CBT or guided self‑help should be referred for review by a tier 2 or 3 CAMHS team. [2005]

1.5.2.4 Antidepressant medication should not be used for the initial treatment of children and young people with mild depression. [2005]

1.5.2.5 The further treatment of children and young people with persisting mild depression unresponsive to treatment at tier 1 or 2 should follow the guidance for moderate to severe depression (see section 1.6 below). [2005]

1.6 Steps 4 and 5: Moderate to severe depression

1.6.1 Treatments for moderate to severe depression

See recommendation 1.5.2.1 on discussions to have with children and young people and their family members or carers (as appropriate) before starting psychological therapies.

1.6.1.1 Children and young people presenting with moderate to severe depression should be reviewed by a CAMHS tier 2 or 3 team. [2005]

1.6.1.2 Offer children and young people with moderate to severe depression a specific psychological therapy (individual CBT, interpersonal therapy, family therapy, or psychodynamic psychotherapy) that runs for at least 3 months. [new 2015]

1.6.2 Combined treatments for moderate to severe depression

1.6.2.1 Consider combined therapy (fluoxetine[2] and psychological therapy) for initial treatment of moderate to severe depression in young people (12–18 years), as an alternative to psychological therapy followed by combined therapy and to recommendations 1.6.2.2–1.6.2.4. [new 2015]

1.6.2.2 If moderate to severe depression in a child or young person is unresponsive to psychological therapy after four to six treatment sessions, a multidisciplinary review should be carried out. [2005]

1.6.2.3 Following multidisciplinary review, if the child or young person's depression is not responding to psychological therapy as a result of other coexisting factors such as the presence of comorbid conditions, persisting psychosocial risk factors such as family discord, or the presence of parental mental ill‑health, alternative or perhaps additional psychological therapy for the parent or other family members, or alternative psychological therapy for the patient, should be considered. [2005]

1.6.2.4 Following multidisciplinary review, offer fluoxetine[3] if moderate to severe depression in a young person (12–18 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions. [2015]

1.6.2.5 Following multidisciplinary review, cautiously consider fluoxetine[4] if moderate to severe depression in a child (5–11 years) is unresponsive to a specific psychological therapy after 4 to 6 sessions, although the evidence for fluoxetine's effectiveness in this age group is not established. [2015]

1.6.3 Depression unresponsive to combined treatment

1.6.3.1 If moderate to severe depression in a child or young person is unresponsive to combined treatment with a specific psychological therapy and fluoxetine after a further six sessions, or the patient and/or their parent(s) or carer(s) have declined the offer of fluoxetine, the multidisciplinary team should make a full needs and risk assessment. This should include a review of the diagnosis, examination of the possibility of comorbid diagnoses, reassessment of the possible individual, family and social causes of depression, consideration of whether there has been a fair trial of treatment, and assessment for further psychological therapy for the patient and/or additional help for the family. [2005]

1.6.3.2 Following multidisciplinary review, the following should be considered:

  • an alternative psychological therapy which has not been tried previously (individual CBT, interpersonal therapy or shorter‑term family therapy, of at least 3 months' duration), or

  • systemic family therapy (at least 15 fortnightly sessions), or

  • individual child psychotherapy (approximately 30 weekly sessions). [2005]

1.6.4 How to use antidepressants in children and young people

1.6.4.1 Do not offer antidepressant medication to a child or young person with moderate to severe depression except in combination with a concurrent psychological therapy. Specific arrangements must be made for careful monitoring of adverse drug reactions, as well as for reviewing mental state and general progress; for example, weekly contact with the child or young person and their parent(s) or carer(s) for the first 4 weeks of treatment. The precise frequency will need to be decided on an individual basis, and recorded in the notes. In the event that psychological therapies are declined, medication may still be given, but as the young person will not be reviewed at psychological therapy sessions, the prescribing doctor should closely monitor the child or young person's progress on a regular basis and focus particularly on emergent adverse drug reactions. [2015]

1.6.4.2 If an antidepressant is to be prescribed this should only be following assessment and diagnosis by a child and adolescent psychiatrist. [2005]

1.6.4.3 When an antidepressant is prescribed to a child or young person with moderate to severe depression, it should be fluoxetine[4] as this is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks. [2005]

1.6.4.4 If a child or young person is started on antidepressant medication, they (and their parent(s) or carer(s) as appropriate) should be informed about the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed. Discussion of these issues should be supplemented by written information appropriate to the child or young person's and parents' or carers' needs that covers the issues described above and includes the latest patient information advice from the relevant regulatory authority. [2005]

1.6.4.5 A child or young person prescribed an antidepressant should be closely monitored for the appearance of suicidal behaviour, self‑harm or hostility, particularly at the beginning of treatment, by the prescribing doctor and the healthcare professional delivering the psychological therapy. Unless it is felt that medication needs to be started immediately, symptoms that might be subsequently interpreted as side effects should be monitored for 7 days before prescribing. Once medication is started the patient and their parent(s) or carer(s) should be informed that if there is any sign of new symptoms of these kinds, urgent contact should be made with the prescribing doctor. [2005]

1.6.4.6 When fluoxetine[4] is prescribed for a child or young person with depression, the starting dose should be 10 mg daily. This can be increased to 20 mg daily after 1 week if clinically necessary, although lower doses should be considered in children of lower body weight. There is little evidence regarding the effectiveness of doses higher than 20 mg daily. However, higher doses may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority. [2005]

1.6.4.7 When an antidepressant is prescribed in the treatment of a child or young person with depression and a self‑report rating scale is used as an adjunct to clinical judgement, this should be a recognised scale such as the Mood and Feelings Questionnaire (MFQ). [2005]

1.6.4.8 When a child or young person responds to treatment with fluoxetine[4], medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks); in other words, for 6 months after this 8‑week period. [2005]

1.6.4.9 If treatment with fluoxetine is unsuccessful or is not tolerated because of side effects, consideration should be given to the use of another antidepressant. In this case sertraline or citalopram are the recommended second‑line treatments[5]. [2005]

1.6.4.10 Sertraline or citalopram should only be used when the following criteria have been met[5].

  • The child or young person and their parent(s) or carer(s) have been fully involved in discussions about the likely benefits and risks of the new treatment and have been provided with appropriate written information. This information should cover the rationale for the drug treatment, the delay in onset of effect, the time course of treatment, the possible side effects, and the need to take the medication as prescribed; it should also include the latest patient information advice from the relevant regulatory authority.

  • The child or young person's depression is sufficiently severe and/or causing sufficiently serious symptoms (such as weight loss or suicidal behaviour) to justify a trial of another antidepressant.

  • There is clear evidence that there has been a fair trial of the combination of fluoxetine and a psychological therapy (in other words that all efforts have been made to ensure adherence to the recommended treatment regimen).

  • There has been a reassessment of the likely causes of the depression and of treatment resistance (for example other diagnoses such as bipolar disorder or substance abuse).

  • There has been advice from a senior child and adolescent psychiatrist – usually a consultant.

  • The child or young person and/or someone with parental responsibility for the child or young person (or the young person alone, if over 16 or deemed competent) has signed an appropriate and valid consent form. [2005]

1.6.4.11 When a child or young person responds to treatment with citalopram or sertraline[5], medication should be continued for at least 6 months after remission (defined as no symptoms and full functioning for at least 8 weeks). [2005]

1.6.4.12 When an antidepressant other than fluoxetine[4] is prescribed for a child or young person with depression, the starting dose should be half the daily starting dose for adults. This can be gradually increased to the daily dose for adults over the next 2 to 4 weeks if clinically necessary, although lower doses should be considered in children with lower body weight. There is little evidence regarding the effectiveness of the upper daily doses for adults in children and young people, but these may be considered in older children of higher body weight and/or when, in severe illness, an early clinical response is considered a priority. [2005]

1.6.4.13 Paroxetine and venlafaxine should not be used for the treatment of depression in children and young people. [2005]

1.6.4.14 Tricyclic antidepressants should not be used for the treatment of depression in children and young people. [2005]

1.6.4.15 Where antidepressant medication is to be discontinued, the drug should be phased out over a period of 6 to 12 weeks with the exact dose being titrated against the level of discontinuation/withdrawal symptoms. [2005]

1.6.4.16 As with all other medications, consideration should be given to possible drug interactions when prescribing medication for depression in children and young people. This should include possible interactions with complementary and alternative medicines as well as with alcohol and 'recreational' drugs. [2005]

1.6.4.17 Although there is some evidence that St John's wort may be of some benefit in adults with mild to moderate depression, this cannot be assumed for children or young people, for whom there are no trials upon which to make a clinical decision. Moreover, it has an unknown side‑effect profile and is known to interact with a number of other drugs, including contraceptives. Therefore St John's wort should not be prescribed for the treatment of depression in children and young people. [2005]

1.6.4.18 A child or young person with depression who is taking St John's wort as an over‑the‑counter preparation should be informed of the risks and advised to discontinue treatment while being monitored for recurrence of depression and assessed for alternative treatments in accordance with this guideline. [2005]

1.6.5 The treatment of psychotic depression

See also the NICE guideline on psychosis and schizophrenia in children and young people.

1.6.5.1 For children and young people with psychotic depression, augmenting the current treatment plan with an atypical antipsychotic medication[6] should be considered, although the optimum dose and duration of treatment are unknown. [2005]

1.6.5.2 Children and young people prescribed an atypical antipsychotic medication should be monitored carefully for side effects. [2005]

1.6.6 Inpatient care

1.6.6.1 Inpatient treatment should be considered for children and young people who present with a high risk of suicide, high risk of serious self‑harm or high risk of self‑neglect, and/or when the intensity of treatment (or supervision) needed is not available elsewhere, or when intensive assessment is indicated. [2005]

1.6.6.2 When considering admission for a child or young person with depression, the benefits of inpatient treatment need to be balanced against potential detrimental effects, for example loss of family and community support. [2005]

1.6.6.3 When inpatient treatment is indicated, CAMHS professionals should involve the child or young person and their parent(s) or carer(s) in the admission and treatment process whenever possible. [2005]

1.6.6.4 Commissioners and strategic health authorities should ensure that inpatient treatment is available within reasonable travelling distance to enable the involvement of families and maintain social links. [2005]

1.6.6.5 Commissioners and strategic health authorities should ensure that inpatient services are able to admit a young person within an appropriate timescale, including immediate admission if necessary. [2005]

1.6.6.6 Inpatient services should have a range of interventions available including medication, individual and group psychological therapies and family support. [2005]

1.6.6.7 Inpatient facilities should be age appropriate and culturally enriching, with the capacity to provide appropriate educational and recreational activities. [2005]

1.6.6.8 Planning for aftercare arrangements should take place before admission or as early as possible after admission and should be based on the Care Programme Approach. [2005]

1.6.6.9 Tier 4 CAMHS professionals involved in assessing children or young people for possible inpatient admission should be specifically trained in issues of consent and capacity, the use of current mental health legislation and the use of childcare laws, as they apply to this group of patients. [2005]

1.6.7 Electroconvulsive therapy

1.6.7.1 ECT should only be considered for young people with very severe depression and either life‑threatening symptoms (such as suicidal behaviour) or intractable and severe symptoms that have not responded to other treatments. [2005]

1.6.7.2 ECT should be used extremely rarely in young people and only after careful assessment by a practitioner experienced in its use and only in a specialist environment in accordance with NICE recommendations. [2005]

1.6.7.3 ECT is not recommended in the treatment of depression in children
(5–11 years). [2005]

1.6.8 Discharge after a first episode

1.6.8.1 When a child or young person is in remission (less than two symptoms and full functioning for at least 8 weeks) they should be reviewed regularly for 12 months by an experienced CAMHS professional. The exact frequency of contact should be agreed between the CAMHS professional and the child or young person and/or the parent(s) or carer(s) and recorded in the notes. At the end of this period, if remission is maintained, the young person can be discharged to primary care. [2005]

1.6.8.2 CAMHS should keep primary care professionals up to date about progress and the need for monitoring of the child or young person in primary care. CAMHS should also inform relevant primary care professionals within 2 weeks of a patient being discharged and should provide advice about whom to contact in the event of a recurrence of depressive symptoms. [2005]

1.6.8.3 Children and young people who have been successfully treated and discharged but then re‑referred should be seen as soon as possible rather than placed on a routine waiting list. [2005]

1.6.9 Recurrent depression and relapse prevention

1.6.9.1 Specific follow‑up psychological therapy sessions to reduce the likelihood of, or at least detect, a recurrence of depression should be considered for children and young people who are at a high risk of relapse (for example individuals who have already experienced two prior episodes, those who have high levels of subsyndromal symptoms, or those who remain exposed to multiple‑risk circumstances). [2005]

1.6.9.2 CAMHS specialists should teach recognition of illness features, early warning signs, and subthreshold disorders to tier 1 professionals, children or young people with recurrent depression and their families and carer(s). Self‑management techniques may help individuals to avoid and/or cope with trigger factors. [2005]

1.6.9.3 When a child or young person with recurrent depression is in remission (less than two symptoms and full functioning for at least 8 weeks) they should be reviewed regularly for 24 months by an experienced CAMHS professional. The exact frequency of contact should be agreed between the CAMHS professional and the child or young person and/or the parent(s) or carer(s) and recorded in the notes. At the end of this period, if remission is maintained, the young person can be discharged to primary care. [2005]

1.6.9.4 Children and young people with recurrent depression who have been successfully treated and discharged but then re‑referred should be seen as a matter of urgency. [2005]

1.7 Transfer to adult services

1.7.1.1 The CAMHS team currently providing treatment and care for a young person aged 17 who is recovering from a first episode of depression should normally continue to provide treatment until discharge is considered appropriate in accordance with this guideline, even when the person turns 18 years of age. [2005]

1.7.1.2 The CAMHS team currently providing treatment and care for a young person aged 17–18 who either has ongoing symptoms from a first episode that are not resolving or has, or is recovering from, a second or subsequent episode of depression should normally arrange for a transfer to adult services, informed by the Care Programme Approach. [2005]

1.7.1.3 A young person aged 17–18 with a history of recurrent depression who is being considered for discharge from CAMHS should be provided with comprehensive information about the treatment of depression in adults (including the NICE 'Information for the public' version for adult depression) and information about local services and support groups suitable for young adults with depression. [2005]

1.7.1.4 A young person aged 17–18 who has successfully recovered from a first episode of depression and is discharged from CAMHS should not normally be referred on to adult services, unless they are considered to be at high risk of relapse (for example, if they are living in multiple‑risk circumstances). [2005]

Terms used in this guideline

Active listening A way of listening that focuses entirely on what the other person is saying and confirms understanding of both the content of the message and the emotions and feelings underlying the message to ensure that understanding is accurate.

Adherence The behaviour of taking medicine according to treatment dosage and schedule as intended by the prescriber. In this guideline, the term adherence is used in preference to the term compliance, but is not synonymous with concordance, which has a number of different uses and meanings.

Adverse drug reaction Any undesirable experience that results from the administration of a pharmacologically active agent.

Bipolar disorder This condition is also known as manic depression. It is an illness that affects mood, causing a person to switch between feeling very low (depression) and very high (mania).

CAMHS Child and Adolescent Mental Health Service(s).

CAMHS link worker See Primary mental health worker

Care Programme Approach (CPA) Introduced in 1991, this approach was designed to ensure that different community services are coordinated and work together towards a particular person's care. This approach requires that professionals from the health authority and local authority get together to arrange care, and applies to all patients accepted for care by the specialist mental health services.

Child An individual aged 5–11 years.

Child and Adolescent Psychiatric Assessment (CAPA) An interviewer‑based diagnostic interview with versions for use with children and their parent(s).

Cognitive behavioural therapy (CBT) A range of behavioural and cognitive behavioural therapies, in part derived from the cognitive behavioural model of affective disorders, in which the patient works collaboratively with a therapist using a shared formulation to achieve specific treatment goals. These may include recognising the impact of behavioural and/or thinking patterns on feeling states and encouraging alternative cognitive and/or behavioural coping skills to reduce the severity of target symptoms and problems.

Conversational technique This term is used in the guideline to emphasise the importance of a two‑way communication. A collaboration between patient and healthcare professional aims to ensure that the patient feels able to express their feelings in the healthcare setting safe in the knowledge that their healthcare professional will listen.

Depression (major depressive disorder) The guideline uses the ICD‑10 definition in which 'an individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other symptoms are: (a) reduced concentration and attention; (b) reduced self‑esteem and self‑confidence; (c) ideas of guilt and unworthiness (even in a mild type of episode); (d) bleak and pessimistic views of the future; (e) ideas or acts of self‑harm or suicide; (f) disturbed sleep; (g) diminished appetite.'

Depression unresponsive to treatment Depression that has failed to respond to two or more antidepressants taken at an adequate dose for an adequate duration given sequentially.

Dysphoria An emotional state characterised by malaise, anxiety, depression or unease.

Dysthymia A chronic depression of mood which does not currently fulfil the criteria for recurrent depressive disorder, of mild or moderate severity, in terms of either severity or duration of individual episodes. There are variable phases of mild depression and comparative normality. Despite tiredness, feeling down and not enjoying much, people with dysthymia are usually able to cope with everyday life.

Effectiveness The extent to which a specific intervention, when used under ordinary circumstances, does what it is intended to do. Clinical trials that assess effectiveness are sometimes called management trials.

Efficacy The extent to which an intervention produces a beneficial result under ideal conditions. Clinical trials that assess efficacy are sometimes called explanatory trials and are restricted to participants who fully cooperate. The randomised controlled trial is the accepted 'gold standard' for evaluating the efficacy of an intervention.

Electroconvulsive therapy (ECT) A therapeutic procedure in which an electric current is briefly applied to the brain to produce a seizure. This is used for treatment of severe depression symptoms or to ease depression that isn't responding well to other forms of treatment. It is sometimes called convulsive therapy, electroshock therapy or shock therapy.

Family therapy Family therapy sessions based on systemic, cognitive behavioural or psychoanalytic principles, which may include psychoeducational, problem‑solving and crisis management work, and might involve specific interventions with a depressed child or young person.

Guided self‑help A self‑administered intervention designed to treat depression, which makes use of a range of books or a self‑help manual that is based on an evidence‑based intervention and is designed specifically for the purpose.

Guideline Development Group (GDG) The group of academic experts, clinicians and service user representatives responsible for developing the guideline.

Guideline implementation Any intervention designed to support the implementation of guideline recommendations.

Guideline recommendation A systematically developed statement that is derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate evidence relating to the specific condition in question.

Healthcare professionals A generic term used in this guideline to coverall health professionals such as GPs, psychologists, psychotherapists, psychiatrists, paediatricians, school doctors, nurses (including school and community based), health visitors, counsellors, art therapists, music therapists, drama therapists and family therapists who work with children and young people and whose work may involve considering the young person's additional psychological needs.

Kiddie Schedule for Affective Disorders and Schizophrenia (K‑SADS) An interviewer‑led procedure for diagnostic assessment of depression including the severity of the current episode designed for use by trained individuals with some clinical experience with participants aged 6–17 years.

Meta‑analysis The use of statistical techniques in a systematic review to integrate the results of several independent studies.

Mild depression Four depressive symptoms as defined by the ICD‑10.

Moderate depression Five or six depressive symptoms as defined by the ICD‑10.

Mood and Feelings Questionnaire (MFQ) A self‑report measure used to screen for depression.

Multidisciplinary review A comprehensive review of the child or young person's situation that involves professionals additional to the therapist(s) delivering treatment. This review should consider a range of sources of information including evidence of functioning at home, school and other relevant settings and should take account of the wishes of the child or young person and their parent(s) or carer(s).

Multidisciplinary team For the purposes of this guideline this term refers to professionals who are involved in the care of a child or young person working in partnership across all tiers. Members of the team are likely to include healthcare professionals (including CAMHS professionals, GPs, health visitors and school nurses), teachers, social services and voluntary agencies.

Non‑directive supportive therapy (NDST) This therapy involves the planned delivery of direct individual contact time with an empathic, concerned and skilled non‑specialist CAMHS professional to offer emotional support and non‑directive problem solving as appropriate and to review the child or young person's state (for example, depressive symptoms, school attendance, suicidality, recent social activities) in order to assess whether specialist help is needed.

Primary mental health worker (PMHW) Sometimes also called 'CAMHS link worker'. This role was described in NHS Health Advisory Service, Together We Stand (London: NHS Health Advisory Service, 1995) and was recommended as a way of improving the relationship, communication and collaboration between specialist mental health services (CAMHS) and the wider network of services working with children, such as schools, youth and community services, primary care, etc. Primary mental health workers tend to operate in tiers 1 and 2. In some parts of the UK, including Scotland, this has led to the establishment of PMHW posts. In other areas the role has been developed, but delivered in a variety of ways. In some cases, workers are employed specifically to deliver primary mental health work, whilst in others, this work is achieved through an extension of pre‑existing professional roles.

Psychoanalytic/psychodynamic child psychotherapy Psychodynamic interventions are defined as psychological therapies derived from a psychodynamic/psychoanalytic model, and where:

1. Therapist and patient explore and gain insight into conflicts and problem behaviours, modes of thought and relating and how these are represented in current situations and relationships including the therapy relationship (for example, transference and counter‑transference).

2. This leads to patients being given an opportunity to explore through play, drawing, talking and behaviour, feelings and conscious and unconscious conflicts, originating in the past or in learnt behaviour. The technical focus is on interpreting and working through conflicts and recurrent problematic areas of behaviour and relating as they manifest in the treatment situation.

3. Therapy is non‑directive and recipients are not taught specific skills (such as thought monitoring, re‑evaluating, or problem solving).

Psychological therapies A group of treatment methods that involve psychosocial rather than physical intervention. They include cognitive behavioural therapy, family therapy, systemic family therapy, non‑directive supportive therapy, psychodynamic psychotherapy, group psychotherapy, counselling, art therapy, interpersonal psychotherapy, guided self‑help and any other form of treatment that aims to be helpful through the communication of thoughts and feelings in the presence of a therapist, who works with the material using a systematic framework for understanding and responding to it.

Racial identity status An individual's perception of himself or herself as belonging to a racial group; also the beliefs, morals and attitudes that are shared with a particular racial group in contrast with other groups. It has been suggested that racial identity is integral to personality and is a key dynamic factor in psychotherapeutic dyads.

Randomisation A method used to generate a random allocation sequence, such as using tables of random numbers or computer‑generated random sequences. The method of randomisation should be distinguished from concealment of allocation, because if the latter is inadequate, selection bias may occur despite the use of randomisation. For instance, a list of random numbers may be used to randomise participants, but if the list were open to the individuals responsible for recruiting and allocating participants, those individuals could influence the allocation process, either knowingly or unknowingly.

Randomised controlled trial (RCT) (also termed randomised clinical trial) An experiment in which investigators randomly allocate eligible people into groups to receive or not to receive one or more interventions that are being compared. The results are assessed by comparing outcomes in the different groups. Through randomisation, the groups should be similar in all aspects apart from the treatment they receive during the study.

Recurrent depression The development of a depressive disorder in a person who has previously suffered from depression.

Relapse The reappearance of disease signs and symptoms after apparent remission. The definitions of relapse used in the review in the guideline were those adopted by the individual studies and varied between studies.

Remission Diminution or disappearance of symptoms.

Risk profiling A structured assessment and analysis of those factors in a child or young person's environment and history that are known to increase the risk of depression.

Screening Screening is defined by the Guideline Development Group as a simple test performed on a large number of people to identify those who have depression.

Self‑help Any activity or lifestyle choice that an individual makes in the belief that it will confer therapeutic benefit.

Severe depression Seven or more depressive symptoms as defined by the ICD‑10.

Sleep hygiene Behavioural practices that promote continuous and effective sleep.

Stepped care A considered, organised, coordinated approach to screening, assessment, treatment and onward referral by an individual practitioner, team or care provider organisation, within the parameters of defined protocols or pathways. These approaches may or may not be provided within the context of a fixed budget (for example, the Health Maintenance Organisation [HMO] in the USA). Local healthcare commissioning organisations are required to develop protocols for the treatment of depression in primary care within the National Service Framework for Mental Health.

Stepped‑care model A sequence of treatment options offering simpler and less expensive interventions first and more complex and expensive interventions if the patient has not benefited, based on locally agreed protocols.

Subsyndromal depression (subthreshold depression) Depressive symptoms that fail to meet the criteria for major depressive disorder. This type of depression is not covered by this guideline.

Suicidal ideation Thoughts about suicide or of taking action to end one's own life.

Tier 1 Primary care services including GPs, paediatricians, health visitors, school nurses, social workers, teachers, juvenile justice workers, voluntary agencies and social services.

Tier 2 CAMHS Services provided by professionals relating to workers in primary care including clinical child psychologists, paediatricians with specialist training in mental health, educational psychologists, child and adolescent psychiatrists, child and adolescent psychotherapists, counsellors, community nurses/nurse specialists and family therapists.

Tier 3 CAMHS Specialised services for more severe, complex or persistent disorders including child and adolescent psychiatrists, clinical child psychologists, nurses (community or inpatient), child and adolescent psychotherapists, occupational therapists, speech and language therapists, art, music and drama therapists, and family therapists.

Tier 4 CAMHS Tertiary‑level services such as day units, highly specialised outpatient teams and inpatient units.

Tricyclic antidepressants (TCAs) The original class of antidepressants used to treat depression by increasing levels of the neurotransmitters serotonin and noradrenaline.

Watchful waiting An intervention in which no active treatment is offered to the person with depression if, in the opinion of the healthcare professional, the person may recover without a specific intervention. All such patients should be offered a follow‑up appointment.

Young person An individual aged between 12 and 18.



[2] At the time of publication (March 2015), fluoxetine did not have UK marketing authorisation for use in young people (aged 12–18), without a previous trial of psychological therapy that was ineffective. For combined antidepressant treatment and psychological therapy as an initial treatment, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[3] At the time of publication (March 2015), fluoxetine was the only antidepressant with UK marketing authorisation for use in this indication for children and young people aged 8 to 18.

[4] At the time of publication (March 2015), fluoxetine did not have a UK marketing authorisation for use in children under the age of 8 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[5] At the time of publication (March 2015), citalopram is not licensed for use in children and young people under 18 and sertraline is not licensed for use in children and young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[6] At the time of publication (March 2015), none of the atypical antipsychotics were licensed for use in this indication for children and young people under 18. Licensed indications for the atypical antipsychotics vary and clinicians should refer to the individual summary of product characteristics for licensing information. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

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